{
"Npi": {
"NPI": "1417259326",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "VG WELLNESS PHARMACY, INC.",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": "6",
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "5028 BOSTON AVENUE",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "GLENDALE",
"MailingAddressStateName": "CA",
"MailingAddressPostalCode": "91214-1013",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "818-279-5407",
"MailingAddressFaxNumber": "213-388-4200",
"FirstLinePracticeLocationAddress": "440 S VERMONT AVE",
"SecondLinePracticeLocationAddress": "STE 109",
"PracticeLocationAddressCityName": "LOS ANGELES",
"PracticeLocationAddressStateName": "CA",
"PracticeLocationAddressPostalCode": "90020-1987",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "213-388-4100",
"PracticeLocationAddressFaxNumber": "213-388-4200",
"EnumerationDate": "11/29/2010",
"LastUpdateDate": "01/19/2022",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "KOO",
"AuthorizedOfficialFirstName": "KYUNGJOO",
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": "PHARMACIST IN CHARGE",
"AuthorizedOfficialNamePrefix": "MS.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "RPH",
"AuthorizedOfficialTelephoneNumber": "213-388-4100",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "3336C0003X",
"TaxonomyName": "Community/Retail Pharmacy",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}